Therapy such as speech therapy and physical therapy can often be a powerful tool in the treatment of many diseases and injuries. Therapy can be provided either alone or in conjunction with other medical treatments or interventions. However, pharmaceutical and/or surgical interventions are often not sufficient for improving physical limitations (e.g., speech and motor limitations) associated with many medical conditions. Behavioral therapeutic programs can therefore be a key tool in a patient's rehabilitation and recovery. For example, speech therapy is often used to improve speech/language impairments in patients with Parkinson's disease whose speech production deteriorates during the disease process. Similarly, physical therapy is often used to reduce symptoms of movement disorders in patients with Parkinson's disease.
However, speech and physical therapy may have several limitations when treating various neurological disorders, such as Parkinson' disease. First, speech and physical therapy are always given as separate treatment by separate professionals. Second, the overall treatment program and components thereof are typically targeted only to the symptoms of the patient. Third, treatments are typically of low intensity in that various tasks may only be performed once in each session and treatment sessions may only be delivered once or twice per week. Fourth, treatments typically have multiple foci, such as volume, rate, breath support, and enunciation for speech therapy and balance, gait, and reaching for physical therapy. Fifth, each subcomponent of a breakdown (e.g., in communication, speech, language, and swallowing and in physical therapy, balance, gait, mobility) are trained individually by specific exercises targeting each subcomponent. These drawbacks are explored further below.
It is a common practice worldwide for patients to receive separate therapy from therapists of different disciplines to treat limb and speech motor disorders. For example, a patient with Parkinson's disease may see a speech therapist for communication disorders, a physical therapist for limb and gait disorders, and an occupational therapist for improving activities of daily living, such as eating and dressing. These therapeutic interventions often target a specific motor system, for example the speech motor system, the language system, or the limb motor systems (e.g., reaching, walking) of a patient in isolation and usually by distinct therapists or teachers. Often, these separate therapies are delivered at different times (e.g., receive physical therapy several months after receiving speech therapy).
Most often, the specific exercises used in treatment are chosen based upon a patient's response to a detailed assessment, evaluating each subcomponent of the production system. For example, the speech clinician evaluates the speech production system (respiratory, phonatory, articulatory and velopharyngeal systems), the language system (sematics, syntax, phonology, pragmatics) and swallowing and any breakdowns observed are targeted in treatment with specific exercises directed to the specific breakdown. For example, tongue weakness may be addressed with tongue strengthening exercises, soft volume may be addressed by breathing exercises and syntax may be addressed by exercises focusing on the specific linguistic deficit. Similarly in movement, the physical therapist evaluates posture, upper and lower extremities and balance and any breakdowns observed are targeted in treatment with exercises directed to the specific breakdown. For example, lower extremity weakness would be targeted by specific leg strengthening exercises and upper extremity weakness would be targeted by specific arm strengthening exercises
When therapists try to teach patients to improve their disorder they often use multiple instructions to achieve the speech or limb motor goal. For example, during speech treatment, patients may be cued to “slow down, take a deep breath, over articulate, and talk louder.” In separate treatment sessions, the same patient may have multiple instructions to improve physical functioning, such as “scoot forward to edge of chair, lean forward, and push up.” Both traditional speech and physical therapy programs have limited long-term efficacy. Patient compliance with programs is variable, due to often limited positive impact on function, perhaps related to difficulty in carrying out multi-step tasks and practicing multiple treatment regimes in individuals who may have cognitive challenges to learning.
An example of a neurological disorder is Parkinson's disease (paralysis agitans). Parkinson's disease is a neurodegenerative disease of brain, specifically an area called the substantia nigra pars compacta (an area in the basal ganglia of the brain that produces a neurotransmitter called dopamine). The disease involves a progressive loss of dopamine, resulting in a movement disorder of the extrapyramidal system, which controls and adjusts communication between neurons in the brain and muscles in the human body. It also commonly involves disturbances of sensory systems related to the awareness of movement. Disordered voice and speech characteristics of individuals with Idiopathic Parkinson's Disease (IPD) are frequently related to the motor signs of the disease (rigidity, bradykinesia, hypokinesia, tremor). Reduced amplitude of movement (hypokinesia) and slowed movement (bradykinesia), which are observed across motor systems in individuals with IPD, have been associated with “the cortical motor centers being inadequately activated by excitatory circuits passing through the basal ganglia” (Penny & Young, 1983) and subsequent reduced drive to motoneuron pools. This may be manifest in reduced movement during walking (reduced arm swing, shuffling gait), writing (micrographia) and talking (soft voice) (Beneke et al., 1987; Hallet and Khoshbin, 1980; Tatton, Eastman, Bedingham, Verrier, & Bruce, 1984; Wisendanger and Rüegg, 1978).
While the causes of neurological disorders such as Parkinson's disease are not entirely understood, one theory about what causes movement problems in a patient suffering from Parkinson's disease relates to their inadequate cortical drive (activation) to the muscle resulting in inadequate and variable force production. The movements that are most impaired are the ones most automated or repetitive (e.g. walking, sit-to-stand, speaking, etc.). Due to the slow onset, patients adapt to slower and smaller movements and fail to self-correct their movement patterns, despite having the potential to move and speak at normal bigness/loudness. When asked to perform movements of normal bigness/loudness they do so; but report it is effortful and that the movement feels too big/loud or abnormal.
A patient with Parkinson's disease may have symptoms in several areas, such as speech, movement and/or motor control. Therefore, a patient with Parkinson's disease is often treated with a plurality of therapies designed to target the patient's symptoms and help him regain at least minimal functionality in the affected area or areas. Some common therapy practices include speech/language therapy, physical therapy, occupational therapy and co-therapy. Co-therapy can involve two or more therapists working with a patient on separate tasks in a particular therapy session.
Some techniques used in these therapy sessions include, using exercises that practice one skill at a time, breaking down skills into particular component skills to make them easier to perform, and focusing on performing the skill correctly. Practicing one skill at a time and breaking down skills into particular component skills are techniques that allow a therapist to adjust the therapy session to match a particular patient's level of functioning in a particular area (e.g., dexterity, motor control, or enunciation). For example, a speech therapist may use a book of standard phrases (e.g., dysarthria word lists) that uses random speech material for speech practice but does not target a particular problem area (e.g., enunciating each syllable). The books of phrases may vary based on the difficulty level and the therapist will often choose a book that is appropriate to a particular patient's level of speech quality/functioning. Therapists also often ask the patient to practice the skills until the patient is able to perform the skills or random material at a certain level correctly. After the therapist is satisfied that the patient can perform the skill or level correctly, the therapist advances the patient to a new skill or skill level. In speech therapy, this new skill or set of skills may be contained in a different book of standard phrases. A disadvantage of teaching only skill-level specific skills to patients is that new skills must be learned when the patient advances past the appropriate level of a skill. Learning a new skill is inefficient because of the time and effort it takes simply to learn the new skill before practice is able to begin on the therapeutic techniques embodied in the new skill.
In addition, speech treatment typically focuses on one global skill area at a time. For example, in speech therapy, motor speech practice is separately trained from language and cognitive practice as well as swallowing problems. A speech clinician uses different techniques and materials as well as targets for the patient to train the speech motor system, the language system, and the swallowing function. A disadvantage of this is that the integration of these subcomponents into functional speech production is uncommon.
Another broad category of therapy techniques uses external cues (visual, auditory, attentional/cognitive) to help a patient understand how loud/quickly to speak or where to place her hands/feet. These techniques may also be called compensatory strategies with external cues. In order to counteract a patient's difficulty in producing the adequate muscle activation (force) to perform a task correctly, a therapist may teach the patient compensatory strategies using external cues. An example of these external cues may include strips of masking tape set on floors at regular intervals to provide visual feedback to guide the patient to compensate his/her movement with larger steps until it outwardly conforms to the placement of the tape. Other example may include a metronome used to provide a rhythm cue to guide the patient to compensate his/her speech to a faster/slower rate to conform to the metronome or a voice light to provide a sound level cue, allowing the patient to compensate his/her speech to conform to the loudness level required by the voice light. A disadvantage of using an external cue is that it requires a logical process to be performed by the patient. First, the patient must recognize the cue as an external reminder (e.g., for guiding movement or speech). Second, the patient must determine whether the outward expression of the skill or function he is performing (e.g., movement or speech) matches the guidance provided by the cue (e.g., length of the movement as marked out by strips of masking tape, loudness of the sound as provided by the sound level light, or rhythm of the sound as provided by the metronome). Third, the patient must adjust the effort given to the skill or function, if needed. Another disadvantage is that the patient who uses external cues as a guide for coping with reduced functionality becomes dependent on these external cues and must think to reference the external cues in order to use their guidance. Another disadvantage of using external cues is that they're often difficult to replicate outside of a controlled setting. For example, masking tape must be applied to services in order to be used as an external cue and metronomes/voice lights need to be carried, set up, and calibrated.
Therapy programs are often designed to target specific parts of a skill that is lacking in a patient, or even random words out of a list (in the case of speech therapy). Thus, therapy techniques may be of a type that the patient is unable to perform the techniques outside of the therapy session. The techniques may also be specially designed for use within the therapy session and/or may not be suitable for use or practice in a real-world session. For example, a phrase practiced in a therapy session and/or at home may be inappropriate for the patient to use in a conversation at a grocery store or in a phone call to a friend.
Therapy techniques may be applied to patients with a range of abilities. It is common for a therapist to guide a patient to perform a technique that is appropriate for what the patient can comfortably perform. Common therapy techniques include a focus on training the patient to perform a skill that allows the patient to better cope with his reduced functionality. Training a patient to cope with reduced functionality may avoid addressing or reversing the cause of the reduced functionality, and may, therefore, allow the functionality to become further reduced. Also, training a patient to cope with reduced functionality, even if successful, may result in the patient becoming dependent on the methods required to cope with the reduced functionality and/or may limit the patient to that level of functionality. If the patient is dependent on these methods, the patient may have limited flexibility in planning when and how to perform the skills that allow him to cope with his reduced functionality. Furthermore, if the patient's functionality is further reduced, he may have to re-learn the coping skills or may have to learn entirely new skills in order to cope with his further reduced functionality. Several other factors may reduce the amount of therapeutic progress attainable in a given period of time. For example, to adjust to a patient's decreased level of functioning, therapy techniques for neurological disorders are often practiced at a low intensity, for example one therapy session per week, and may continue for an extended period of time such as a year or more.